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Heart Cardiovascular

Intervention

HE

AR

T- Cardiovascular Intervention

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Table of Contents

Cardiovascular Diseases and Cardiovascular Intervention 2

1 Importance and Status of Cardiovascular Diseases 2

2 History of Cardiovascular Intervention and

Status of Korea 6

1

Why Korea? 12

1 Percutaneous Coronary Intervention (PCI) 12

2 Peripheral Arterial/Aortic Intervention 24

3 Structural Heart Disease Intervention 32

A. Transcatheter aortic valve implantation 29

B. Adult congenital heart disease intervention 32

C. Left atrial appendage closure by surgery 34

2

Korea’s Excellent CardiovascularIntervention Cases 35 3One-stop Medical Service for International Patients 414Korea’s Cardiovascular Intervention Certified Medical Institutions 425

1Cardiovascular Intervention

Smartcare-HEART

2 3

Cardiovascular Diseases and Cardiovascular Intervention

1) Ischemic heart disease—No. 1 cause of death in the world

Based on the statistics in 2017, the No. 1 cause of death in the world is ischemic heart disease,

accounting for 126 deaths per 100,000 persons. The No. 2 cause of death is stroke, with 77 peo-

ple who died of stroke per 100,000 persons. Therefore, both No. 1 and No. 2 are cardiovascular

diseases and cerebrovascular diseases, which means that vascular diseases correspond to 50%

of deaths in the world’s population. Even in Europe, the No. 1 cause of death is ischemic heart

disease. Other cardiovascular diseases, including stroke, are responsible for 40% of the total

number of deaths.

Source: World Health Organization. The top 10 causes of death. January 2017

Ischaemic heart disease1

Stroke2

Chronic obstructive pulmonary disease3

Lower respiratory infections4

Alzheimer disease and other dementias5

Trachea, bronchus, lung cancers6

Diabetes mellitus7

Road injury8

Diarrhoeal diseases9

Tuberculosis10

80 100 120

Crude death rate (per 100,000 population)

0 20 40 60

The 10 main causes of death presented by the World Health Organization in 2017Figure 1

1 Importance and Status of Cardiovascular Diseases

Ischaemic heart disease 19%

Stroke 9%

Other CVD 12%

Stomach cancer 2%

Colo-rectal cancer 3%

Lung cancer 6%

Other cancer 14%

Respiratory disease 7%

Injuries and poisoning 9%

All other causes 19%

Source: European Cardiovascular Disease Statistics 2017

Mortality rate per disease in Europe, 2017Figure 2

However, recently, because of cardiovascular intervention, as well as the management of hy-

pertension, diabetes, and dyslipidemia, and the reduction of the smoking population and the

improvement of lifestyles, the number of deaths related to ischemic heart disease has been

decreasing, and such a trend has been visible in the United States since 2000.

Source: European Cardiovascular Disease Statistics 2017

SlovakiaGreeceFinlandNorwaySpainFrance

Per 1

00,0

00 in

divi

dual

s pe

r yea

r1970 1975 1980 1985 1990 1995 2000 2005 2010

45

40

35

30

25

20

15

10

5

0

Death trend based on ischemic heart disease per 100,000 women (64 years or younger) in each European country for each year

Figure 3

4 5

Cardiovascular Intervention in Korea Smartcare-HEART

The number of deaths caused by ischemic heart disease in Korea that showed an increasing

trend between 1983 and 2002 has been decreasing since then like in Europe and the United

States. In 2012, the numbers of deaths caused by ischemic heart disease were 18.4 people for

males and 8.1 people for females per 100,000 persons.

2) Mortality rate/prevalence rate caused by ischemic heart disease in Korea

According to the data of Statistics Korea in 2018, the deaths caused by heart disease ranked

2nd, next to the deaths caused by cancer, and the number of deaths was 60.2 people per 100,000

persons. Moreover, in the annual mortality rate data on cardiovascular diseases per age group,

the mortality rate showed a rapid increase in elderly people who were 70 years or older.

Source: Statistics Korea, 2018

RankYear of 2017

Cause of Death No. of Death Component Ratio Mortality Rate

1 Malignant neoplasm (Cancer) 78,863 27.6 153.9

2 Heart diseases 30,852 10.8 60.2

3 Neurovascular diseases 22,745 8.0 44.4

4 Pneumonia 19,378 6.8 37.8

5 Intentional self-injury (Suicide) 12,463 4.4 24.3

Causes of death in Korea, 2017 (Top 5)Figure 5

Death trend based on cardiovascular diseases in the United States (age adjusted) Figure 4

2000 2001 2002 2003 2004 2005 2006 2007 2008

400

200

02009 2010 2011 2012 2013 2014

Age-adjusted Mortality Rate

Source: JAMA Cardiology. 2016;1(5):594–99

The prevalence rate of cardiovascular diseases in Korea is between 3,600 and 5,600 people

per 100,000 persons, which means that the number is low compared with other countries in the

world. Furthermore, the number of deaths caused by cardiovascular diseases in Korea is between

91 and 200 people per 100,000 persons, which means that the number is lowest compared with

other countries in the world.

Source: Korean Circ J. 2015;45(3):202–9.

Age

-adj

uste

d de

ath

ra

te p

er 1

0000

0 po

pula

tion

WomenMen

1985 1990 1995 2005 2010

35

30

25

20

15

10

5

0

2000

Age-adjusted mortality from ischemic heart diseaseFigure 6

6 7


1) History of cardiovascular intervention

Source: Roth, G.A. et al. J Am Coll Cardiol. 2017;70(1):1–25

3,601 to 5,6005,601 to 6,6006,601 to 7,5007,501 to 8,500

8,501 to 9,5009,501 to 10,50010,501 to 11,50011,501 to 12,500

Prevalent Cases per 100,000

Prevalent rate of cardiovascular diseases per 100,000 persons in each countryFigure 7

2 History of Cardiovascular Intervention and Status of Korea

1950s

In 1953, Seldinger developed a method to insert a catheter percutaneously without exposing a blood vessel. Coronary angiography was established by Sones, Abrams, Judkins, and oth-ers in the 1960s. Since then, knowledge on the correlation between clinical symptoms and pathophysiology has been obtained, and surgeries for congenital and acquired heart diseases as well as coronary artery bypass graft have been possible.For the following cases, catheters were used according to the initial intention of Forssmann: making a passage between atria in the transposition of great arteries (TGA), patent duc-tus arteriosus (PDA), atrial septal defect (ASD), and inferior vena cava occluder. Moreover, when inserting a permanent pacemaker or an implantable automatic cardioverter defibrillator (IACD), it was used for the injection of insulin, an anticancer chemical agent, an antiarrhythmic drug, etc.

1960sIn 1964, for the first time in the world, Dotter opened a vessel by inserting a catheter into an artery that had been narrowed because of atherosclerosis, and that was how peripheral arterial intervention to vitalize a dying leg and foot began.

1970s

In 1974, Grüntzig modified the latex balloon catheter of Forssmann and made a double-lu-men catheter to penetrate a peripheral artery. After that, this catheter was made smaller and experimented in humans after dogs. Moreover, it was successfully used in an exposed vessel in a patient who was going to receive a surgery because of multivessel coronary artery disease.In 1977, Grüntzig succeeded in the intervention of expanding a coronary stenotic lesion with-out performing a surgery. Among coronary arteries, balloon dilation was performed on a 3 mm stenotic lesion of the left anterior descending artery (LAD), and the result was presented in the academic conference of the American Heart Association in the same year. After that, cardiovascular intervention has been developed remarkably. The development of technolo-gies—such as the materials, structure, designs, etc., of the catheter, balloon catheter, and guidewire—increased the success rate of the procedure and alleviated complications. Af-ter that, the development of vascular imaging equipment—such as coronary angiography, intravascular ultrasound (IVUS), angioscope, optical coherent tomography (OCT), etc.—and the introduction of physiological evaluation methods, such as fractional flow reserve (FFR), became the foundation of generalizing treatment, improving the treatment result, and pop-ularizing the treatment.

1980s–

Present

As the materials and designs of the catheter, balloon catheter, and guidewire were devel-oped; the understanding of pathophysiology was increased; and the procedural technology was developed with accumulated experiences, the intervention has been indicated for all clinical manifestations and pathological forms including the number, form, and location of lesions; myocardial infarction; unstable angina; cardiogenic shock accompanied with myocar-dial infarction; old complete occlusion; and stenosis of the venous graft or arterial graft after performing a bypass graft.Aside from coronary intervention, intervention for peripheral arterial/aortic diseases has been developed and used correspondingly. Intervention for structural heart diseases, such as TAVI, and procedures—such as adult congenital heart disease intervention, left atrial appendage closure by surgery (LAACS), mitral clipping, etc.—have been performed as well.

Initial era

Cardiac catheterization that examines the heart by inserting a catheter to reach the heart via blood vessels was performed on a horse by Claude Bernard for the first time in 1844. In the procedure, catheters were inserted into the right and left ventricles, respectively, by making incisions in the jugular vein and carotid artery.

1920sThe first cardiac catheterization that was performed on a human being was the procedure in which a German surgeon, Werner Forssmann, inserted a catheter into the right ventricle via a vein in his arm in 1929.

1940sCournand and Richards Jr. studied the cardiac physiology of the right side using the method of Forssmann. The first case of the left cardiac catheterization was when Zimmerman et al. exposed the ulnar artery and inserted a French catheter into the left ventricle in 1950.

8 9


2) Cardiovascular intervention status in Korea

According to the K-PCI Registry result of the Korean Society of Interventional Cardiology, the

disease responsible for 75% cases of coronary intervention was acute coronary syndrome (ACS).

For the results of performing coronary intervention, the occurrence rates were 2.3% for deaths

in the hospital, 1.6% for nonlethal myocardial infarction, and 0.2% for stroke. For percutaneous

coronary intervention, a drug-eluting stent (DES) was used for 91.3% of cases, and among them,

for 98% of cases, three or less DESs were used.

3) Research of cardiovascular intervention in Korea

Main international academic journals that have acknowledged researches of cardiovascular

intervention of Korea.

JACC Journal of the American College of Cardiology

JAMAThe Journal of the American

Medical Association

European Heart Journal

The New England Journal of Medicine

(1) Percutaneous coronary intervention

16-month versus 12-month or longer dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome (SMART-DATE): a randomised, open-label, non-inferiority trial. Lancet. 2018;391(10127):1274–84.

2Effect of intravascular ultrasound–guided vs. angiography-guided everolimus-eluting stent implantation: The IVUS-XPL randomized clinical trial. JAMA. 2015;314(20):2155–63.

3Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med. 2015;372(13):1204–12.

4Angiotensin receptor blocker in patients with ST segment elevation myocardial infarction with preserved left ventricular systolic function: prospective cohort study. BMJ. 2014;349:g6650. doi: 10.1136/bmj.g6650.

5Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011;364(18):1718–27.

6Duration of dual antiplatelet therapy after implantation of drug-eluting stents. N Engl J Med. 2010;362(15):1374–82.

7Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med. 2008;358(17):1781–92.

Source: 2014 K-PCI Registry

ST-segment elevation myocardial infarction (STEMI)

18.4%

Non-ST–segment elevation myocardial infarction (NSTEMI)

19.7%

Asymptomatic ischemia

3.5%

Unstable angina

35.9%

Stable angina

22.6%

Classification of the disease causes of patients who received percutaneous coronary intervention in Korea

Figure 8

Source: 2014 K-PCI Registry

Semi-emergency

12%Non-emergency

67%

Rescue therapy

1%Emergency

20%

Status of percutaneous coronary intervention in KoreaFigure 9

10 11


(2) Peripheral arterial/aortic intervention

1Crushed stent with acute occlusion in superficial femoral artery after enhanced external counterpulsation. JACC Cardiovasc Interv. 2014 Oct;7(10):e141–2.

2Prevalence and clinical implications of newly revealed, asymptomatic abnormal ankle–brachial index in patients with significant coronary artery disease. JACC Cardiovasc Interv. 2013 Dec;6(12):1303–13.

3Successful feasibility human trial of a new self-expandable percutaneous pulmonary valve (Pulsta valve) implantation using knitted nitinol wire backbone and trileaflet α-gal-free porcine pericardial valve in the native right ventricular outflow tract. Circ Cardiovasc Interv. 2018 Jun;11(6):e006494.

4Outcomes of acute retrograde type A aortic dissection with an entry tear in descending aorta. Circulation. 2014 Sep 9;130(11 Suppl 1):S39–44.

5Images in cardiovascular medicine. Successful percutaneous renal intervention in a patient with acute traumatic renal artery thrombosis. Circulation. 2006 Nov 14;114(20):e583–5.

6Outcomes of spot stenting versus long stenting after intentional subintimal approach for long chronic total occlusions of the femoropopliteal artery. JACC Cardiovasc Interv. 2015 Mar;8(3):472–480.

7Outcomes of stents covering the deep femoral artery origin. EuroIntervention.2014 Sep;10(5):632–9.

8Risk of rupture or dissection in descending thoracic aortic aneurysm. Circulation. 2015 Oct 27;132(17):1620–9.

9Outcomes of patients with acute type A aortic intramural hematoma. Circulation. 2009 Nov 24;120(21):2046–52.

10Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol. 2007 Aug 21;50(8):799–804.

11Baseline characteristics of a retrospective patient cohort in the Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Diseases (K-VIS ELLA) Registry. Korean Circ J. 2017;47(4):469–76.

12Clinical outcomes of subintimal vs. intraluminal revascularization approaches for long femoropopliteal occlusions in a Korean multicenter retrospective registry cohort. Circ J. 2018;82:1900–7.

13Effects of chronic kidney disease on clinical outcomes in patients with peripheral artery disease undergoing endovascular treatment: Analysis from the K-VIS ELLA registry. Int J Cardiol. 2018;262:32–7.

(3) Structural heart disease intervention

1 Asian TAVR investigators. Clinical outcomes following transcatheter aortic valve replacement in asian population. JACC Cardiovasc Interv. 2016;9(9):926-33.

2 Transcatheter aortic valve replacement with early- and new-generation devices in bicuspid aortic valve stenosis. J Am Coll Cardiol. 2016;68(11):1195–1205.

(1) Percutaneous coronary intervention

8Effect of celecoxib on restenosis after coronary angioplasty with a Taxus stent (COREA–TAXUS trial): an open-label randomised controlled study. Lancet. 2007;370(9587):567–74.

9Effects of intracoronary infusion of peripheral blood stem-cells mobilised with granulocyte-colony stimulating factor on left ventricular systolic function and restenosis after coronary stenting in myocardial infarction: the MAGIC cell randomised clinical trial. Lancet. 2004;363(9411):751–6.

10Multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction with cardiogenic shock. J Am Coll Cardiol. 2018;71(8):844–56.

11Similarity and difference of resting distal to aortic coronary pressure and instantaneous wave-free ratio. J Am Coll Cardiol. 2017;70(17):2114–23.

12Long-term mortality after coronary revascularization in nondiabetic patients with multivessel disease. J Am Coll Cardiol. 2016;68(1):29–36.

13 Effect of statin treatment on modifying plaque composition: a double-blind, randomized study. J Am Coll Cardiol. 2016;67(15):1772–83.

14Coronary microvascular dysfunction as a mechanism of angina in severe AS: prospective adenosine-stress CMR study. J Am Coll Cardiol. 2016;67(12):1412–22.

15Deferred vs. performed revascularization for coronary stenosis with grey-zone fractional flow reserve values: data from the IRIS-FFR registry. Eur Heart J. 2018;39(18):1610–19.

16Clinical implications of three-vessel fractional flow reserve measurement in patients with coronary artery disease. Eur Heart J. 2018;39(11):945–51.

17Intracoronary dual-modal optical coherence tomography–near-infrared fluorescence structural-molecular imaging with a clinical dose of indocyanine green for the assessment of high-risk plaques and stent-associated inflammation in a beating coronary artery. Eur Heart J. 2016;37(37):2833–44.

18Triple versus dual antiplatelet therapy in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Circulation. 2009;119:3207–14.

19Show all authors and for the long-DES-II study investigators. Sirolimus-eluting stent versus paclitaxel-eluting stent for patients with long coronary artery disease. Circulation. 2006;114:2148–53.

20Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: a randomized, controlled trial. Circulation. 2014;129(3):304–12.

13

Smartcare-HEART

Cardiovascular Intervention

12

Why Korea?21) Intervention certificate system

The Korean Society of Interventional Cardiology (KSIC) is leading

the cardiovascular intervention society in Korea and performing the

intervention certification system for the quality management of insti-

tutions and interventional cardiologists. The intervention certification

system is an official acknowledgment of the KSIC with regard to the

desirable intervention level and includes the process of establishing

the quality standard of the medical staff who perform intervention.

Moreover, its purpose is to secure the expertise of the medical staff.

For this, quality improvement is pursued by presenting the standard guidelines on the environ-

ment of the appropriate intervention, facility equipment, and cardiologists. Currently, there are

about 90 institutions and 400 interventional cardiologists in Korea who have been certified by the

KSIC for their practices.

2) Pioneer of the left main coronary artery procedure

In Korea, even during the period when these procedures were prohibited in the guidelines,

the intervention and stent procedure were introduced to treat left main coronary artery lesions,

which led to the left main coronary artery intervention. For the current change and update in the

guidelines that enable performing a stent procedure for left main coronary artery lesions, the ef-

forts and experiences of Korean interventional cardiologists made important contributions. While

Korea is leading the left main coronary artery intervention, the experiences of institutions and

interventional cardiologists have been accumulated, and safe and effective treatment is generally

being performed for left main coronary artery lesions.

3) Leader of cardiovascular physiology

Inserting a stent mechanically into a stenotic lesion with a diameter of more than 50% of the in-

ternal lumen of the patient with a coronary artery disease, especially, stable angina, can make the

prognosis rather worse. Thus, recently, technologies that evaluate cardiovascular physiology—

such as FFR, instantaneous wave free ratio (iFR), etc.—are used to measure the ischemic degree

of heart muscles caused by the stenotic coronary artery, and a strategy of selectively inserting

a stent into a lesion where a significant ischemia is found has been widely accepted gradually.

The intervention society in Korea actively accepted this intervention from the early era to lead the

world’s medicine and medical practice. Such efforts of the intervention society in Korea made

great contributions to change various guidelines that the ischemic degree must be objectively

evaluated first before performing intervention.

4) High performance rate of the radial artery approach procedure

To perform intervention, a sheath is usually inserted into the femoral artery or the radial artery,

and a catheter is replaced, if necessary, for the procedure. By comprehensively considering vari-

ous parameters— such as the status of the patient, location and form of the lesion, complexity of

the procedure, degree of the emergency, etc.—the appropriate route between the femoral artery

and the radial artery is determined by an interventional cardiologist. Recent researches report

that a procedure using the radial artery can reduce complication occurrences and enable moving

in a short time so that the subjective satisfaction of the patient can be improved. For instance,

currently, radial arteries are used in about 30% of cases in the United States but in 60% of cases

in Korea, which means that Korea’s interventional technology is leading the world.

1 Percutaneous Coronary Intervention

14 15

Smartcare-HEARTWhy Korea?

5) High-tech equipment for coronary intervention

(1) Intravascular ultrasound

Intravascular ultrasound (IVUS) is a test in which a micro-ultrasonic transducer (20–50 MHz)

is directly inserted into the coronary artery by following a placed catheter with a size of about 1

mm to obtain the images of the blood vessel lumen and wall. IVUS is relatively easy and safe to

perform, and provides information on the internal structure of the blood vessel. In particular, when

treating complex lesions, such as those of the left main coronary artery and the bifurcation area,

it is used to improve treatment results.

(2) Optical coherence tomography

Optical coherence tomography (OCT) is an imaging technique to evaluate blood vessels using

near infrared. In particular, the resolution is 10 μm so that the structure of the coronary artery

and the stent can be evaluated with the improvement, which is about 10 times better than IVUS.

(3) Fractional flow reserve

Fractional flow reserve (FFR), which is widely performed gradually, is a method that functionally

evaluates how much the coronary artery actually induces ischemia in the heart muscles. By plac-

ing a pressure in the coronary artery and measuring the pressure, the ratio of blood flow before

and after stenosis is estimated. Therefore, whether intervention, such as inserting a stent into the

stenotic lesion, is necessary can be determined.

A. B.

A. Intravascular ultrasound (IVUS) B. OCT (optical coherence tomography)

1 Percutaneous coronary artery intervention

▶Coronary disease

The blood vessel that supplies blood to the heart is called coronary artery. Athero-

sclerosis is a disease characterized by the formation of porridge-shaped atheroma as

a result of the precipitation of cholesterol, inflammatory cells, fibers, calcium, etc., in

the arterial wall to narrow the lumen of the artery.

FFR (fractional flow reserve)Figure 10

Myocardial infarction

Plaque ruptureFibrous plaqueFat depositionTunica adventitia

Tunica media

Tunica intima

Right coronary artery (RCA)

Aorta

Left main coronary artery (LM)

Left circumflex artery (LCX)

Left anterior descending artery (LAD)

Heart and coronary arteryFigure 11

Progression of Atherosclerosis in the coronary artery and pathogenesis of myocardial infarction

Figure 12

16 17


Due to the narrowed lumen caused by arteriosclerosis in the coronary artery, the suffi-

cient amount of blood that the heart requires during exercises cannot be supplied. This

causes chest pain, and this disease is called stable angina. It is important to suspect

the possibility of having stable angina or acute coronary syndrome in all patients who

complain about anterior chest pain. If an atheroma is ruptured or eroded, a thrombus

is formed on the region that blood flow is rapidly deteriorated, which can lead to the

heart muscles becoming damaged; this is called ACS.

2 Diagnosis

(1) Electrocardiogram: ST-segment depression or elevation, T wave inversion, Q

wave, etc., are used to diagnose the possibility of a coronary disease.

(2) Blood test: By measuring cardiac markers, whether heart muscles are damaged

or not can be evaluated.

(3) Exercise stress electrocardiogram: It is used to diagnose stable angina by eval-

uating the pain occurrence status and changes on the electrocardiogram while

running on a machine like a treadmill.

(4) Myocardial SPECT: It has better sensitivity and specificity, and it can also be per-

formed on patients who cannot do exercises.

(5) Coronary CT: Coronary CT has the advantage of being able to diagnose the nar-

rowed lumen of a coronary artery but the disadvantages of radiation exposure and

contrast medium use.

(6) Coronary angiography: It is the most accurate method to evaluate the stenosis

of the coronary artery and has the advantage of treating it immediately once the

disease is confirmed.

3 Percutaneous coronary intervention for coronary disease

In coronary intervention, instead of a heart-opening surgery, a catheter is inserted

via the femoral artery or the radial artery that is directly accessible from the skin and

approached to the coronary artery. The narrowed or occluded coronary artery is ex-

panded using plain old balloon angioplasty (POBA) with the insertion of a metal mesh,

thereby widening the blood vessel to recover blood flow.

In particular, for a patient who has ST-segment elevation myocardial infarction, emer-

gency coronary intervention is performed to have the revascularization within 90 min

from the emergency department visit of the patient. For patients with non-ST seg-

ment elevation myocardial infarction or unstable angina, the early invasive strategy of

performing coronary intervention within 48 hr after the manifestation of symptoms

has been emphasized. For patients with stable angina, by evaluating the symptoms,

degree of myocardial ischemia, location and invasion scope of lesion, etc., compre-

hensively, coronary intervention is performed if pharmacotherapy is not enough to

regulate the symptoms.

Percutaneous coronary intervention (PCI) Figure 13

A. B.

A. Plain old balloon angioplasty (POBA) B. Percutaneous stent implantation

Selective stenting after balloon dilatation· Artery lumen widened insufficiently· Blood vessel torn

Balloon covered with stent

Compressed plaque

Stent expansion

Widened artery

Plaque

Artery widened insufficiently

Plaque

Balloon catheter

Narrowed artery

Catheter Catheter

Balloon dilatation

Plaque

Compressed plaque

Widened artery Widened artery

Widened artery

Coronary artery

18 19


Once percutaneous coronary intervention is performed via the radial artery, moving

is possible right after the procedure, making it the most preferred method nowadays.

A. Chronic total occlusion (CTO) of the left anterior descending artery (LAD) (arrow)

B. Result of successful percutaneous coronary intervention

Percutaneous coronary interventionFigure 14

1) World-class peripheral arterial/aortic intervention results

As for the K-VIS Registry result, the clinical five-year patency rate of the superficial femoral

artery is 80%, which is excellent.

2) Upgraded standardized high-tech medical devices

Essential equipment—such as ultrasound, CT, MRT, the latest angiography, etc.—for diagnos-

ing peripheral arterial disease are available, and the latest medical devices/equipment—such as

DES, drug-eluting balloon, atherectomy device, etc.—have been introduced for use.

3) Active clinical quality evaluation and management activities

Through the registration business in which 31 institutions perform treatment for peripheral

arterial diseases, the quality of treatment is evaluated and managed.

2 Peripheral Arterial/Aortic Intervention

Upgraded standardized high-tech medical devicesFigure 15

20 21


4) High-tech equipment/device for peripheral artery intervention

(1) Atherectomy devices

As devices that reduce the volume of arteriosclerotic plaque, with the expectation of improving

the vascular patency rate after balloon dilation and endovascular treatment, various atherectomy

devices for directional and rotational purposes have been used.

(2) Self-expanding nitinol stent

In general, between an iliac artery lesion and a superficial femoral artery lesion, the longer the

lesion is, the higher the patency is when performing primary stenting instead of balloon dilation.

However, the superficial femoral artery is surrounded by muscles, and there are pressure, twist-

ing, bending, and lengthening caused by the joint exercises of the lower limb, so the common

femoral artery or popliteal artery that is close to the joint has a higher risk of stent fracture. More-

over, as the length of the stent is increased, the risk of stent fracture and restenosis increases.

(3) Self-expanding drug-eluting stent (DES)

The Zilver PTX stent manufactured by Cook Medical is a DES coated with paclitaxel without

having a polymer that delivers drug. As a result of comparing the balloon dilation group with

the drug-eluting stent group, the survival rates without having main incidents (death, lower limb

amputation, interventional reoperation, or surgical treatment) were 83.9% vs. 90.4% in the first

year and 77.9% vs. 86.6% in the second year that the survival rates were significantly higher in

the drug-eluting stent group. Patients who needed stenting after receiving balloon dilation were

compared with the general metal stent group and the drug-eluting stent group, and the patency

rates were 72.9% vs. 90.2% in the first year and 64.1% vs. 83.4% in the second year that the

patency rates were significantly higher in the drug-eluting stent group. Therefore, the effect of a

drug-eluting stent is better than simple balloon dilation or a general metal stent.

(4) Drug-eluting balloon

A drug-eluting balloon has the following advantages: drug is released into a blood vessel to

reduce restenosis, and it does not leave a structure, unlike a metal stent, which is retained per-

manently. Thus, a problem like a stent fracture does not occur, and even if restenosis occurs,

intervention can be performed as if it is a new arteriosclerotic lesion. However, a drug-eluting

balloon cannot effectively solve abnormal blood flow or vascular recoil or remodeling caused by

vascular dissection that occurs after balloon dilation. Therefore, to overcome such problems, addi-

tional stenting is necessary in some patients. As the result of clinical studies in which the recently

launched various drug-eluting balloons were used, the patency of the drug-eluting balloon was

higher than that of the general balloon in all studies.

In most commonly treated lesions, such as femoral artery lesion or popliteal artery lesion, the

paclitaxel-coated drug-eluting balloon or stent significantly reduces restenosis compared with the

general balloon or the general metal stent. However, with regard to the most effective device,

larger and long-term clinical results are necessary so that based on the status of patients and the

characteristics of arterial diseases, the physician in charge would choose a device that would bring

about the best result.

Drug-eluting balloonFigure 16

22 23


1 Peripheral arterial disease / aortic disease

Peripheral arteries refer to all arteries except for the cerebral artery and the coronary

artery. Peripheral artery diseases (PAD) refer to all diseases that occur in peripheral ar-

teries, and the most common disease is the one that narrows or occludes a peripheral

artery. Diseases that occur in the aorta, which is a large blood vessel that is connected

to the heart with the peripheral arteries, are called aortic diseases, and such diseases

as aortic aneurysm, aortic dissection, etc., are examples.

Timetable of arteriosclerosisFigure 17

Normal arterial wall

Normal arterial vessel

Abnormally narrowed arterial vessel

Thickened arterial wall with fatty substances

After 10 years old

After 30 years old

After 40 years old

(1) Symptoms caused by lower limb ischemia: If peripheral arteries that supply blood to the lower limbs become narrowed, pain from the calf, thigh, hip, etc., occurs when walking or doing exercises, which can be relieved by rest; this is called claudication.

(2) Symptoms caused by kidney blood vessel stenosis: If kidney blood vessels are narrowed, kidney function is reduced, and severe hypertension can occur.

(3) Symptoms caused by retinal vessels: If arteriosclerosis becomes severe in the retinal ves-sels, the blood vessels become occluded, which can result in blindness.

(4) Complications of thrombosis/embolism: If there is a disease in an artery or a vein, it is easy for a thrombus to occur in the blood vessel.

(5) Varicose veins: If the function of these valves is reduced, reverse flow occurs that the in-creased pressure in the veins makes the veins of the lower limb crooked and larger; this is called varicose vein in the lower limb.

(6) Inflammatory vascular disease: Inflammation occurs in the blood vessels due to autoimmune diseases, allergic diseases, smoking, etc., thereby narrowing or blocking the blood vessels; this is called inflammatory vascular disease.

Complications of peripheral arterial diseases

2 Diagnosis

(1) Pulse palpation: If pulsation is felt in the abdomen where pulse is generally not

palpated, abdominal aortic aneurysm must be suspected.

(2) Ankle–brachial artery index: The degree of narrowness of the lower limb artery

can be estimated by measuring the blood pressure of the upper limb and the lower

limb simultaneously, and evaluating the ratio.

(3) Vascular ultrasound: Direct imaging of blood vessels close to the body can be

made using ultrasound, and the velocity of the blood flow can be measured that the

degree of the narrowness of an artery can be evaluated.

(4) Computed tomography/magnetic resonance imaging: Computed tomography

imaging after administering contrast medium to a vein provides the status of blood

vessels in a large area.

(5) Angiography: Peripheral arterial angiography is performed when there are clinical

symptoms caused by a peripheral arterial disease, and treatment is considered at the

same time.

Figure 18 Diagnosis

Vascular ultrasound Lower limb artery computed tomography (CT)

24 25


3 Peripheral arterial intervention for a peripheral arterial disease

(1) Peripheral arterial intervention

With regard to peripheral arterial intervention, if a severe stenosis of a peripheral ar-

tery is confirmed, and there is still an unresolved symptom despite pharmacotherapy,

or it is accompanied by a very severe lower limb pain while walking or tissue damage,

peripheral artery dilation is performed using a balloon and a metal mesh at the discre-

tion of the physician in charge.

Compared with blood vessel bypass surgery, the complication occurrence rate is low

for 30 days, and in patients whose long-term survival (i.e., more than two years) is not

expected, trying intravascular treatment first is clinically not worse than performing a

surgery.

In the severely stenotic area of a peripheral artery, a guidewire is placed, and a cathe-

ter with a balloon is inserted. After that, the balloon is expanded to secure the lumen

of the blood vessel.

Figure 19 Balloon dilation: By inserting a balloon into a narrowed blood vessel and expanding it, the degree of narrowness is decreased

If balloon dilation alone cannot secure the lumen enough, or the endothelium of the

blood vessel is dissected, the lumen of the blood vessel is maintained by inserting a

metal mesh.

Figure 20 Stent procedure for a peripheral arterial disease

B.

A. Lesion before the procedure (arrow) B. Expanded blood vessel after the stent procedure

A.

4 Hybrid peripheral artery intervention

Depending on the areas of a peripheral arterial disease, a surgery that bypasses the

narrowed region or that resects the endothelium of the stenosed blood vessel is the

effective treatment whose long-term stability has been proven. However, its disadvan-

tage of invasiveness for a patient cannot be avoided, so the surgical method has been

improved, and less invasive procedures have been developed by coming up with new

equipment to reduce surgical risks.

Hybrid peripheral artery intervention is a fusion of the preexisting surgery and peripheral

artery dilation using a balloon and a stent in the operating room; it reduces the surgery

time and minimizes scars. Moreover, it pursues aesthetic and surgical recovery, as well as

obtaining a clinical result that is similar to that of the preexisting surgery.

Figure 21 Hybrid peripheral artery intervention

A. Blood vessel incision area B. Expanded blood vessel after thrombus removal surgery and stent insertion (arrow)

Blood vessel incision area

B. A.

26 27


5 Aortic intervention for an aortic disease

Abdominal aortic aneurysm is an abdominal aorta that has a diameter of 30 mm or

greater, and 1.5%–5% of the US population with ages of 60 years or older have been

reported to have abdominal aortic aneurysm. In Korea, the diagnosis of abdominal

aortic aneurysm has been increasing because of the increase in CT or abdominal ul-

trasound test.

In endovascular aneurysm repair (EVAR), a stent graft that connects the anterior and

posterior parts of the enlarged aortic aneurysm is placed to isolate the enlarged aorta

from the blood flow so that the aorta is not exposed to pressure anymore; it is an

intervention method for abdominal aortic aneurysm.

As the first procedure done by Juan Parodi in 1991, the number of cases has increased

rapidly for 15 years that the number of procedures was larger than the number of sur-

geries in the United States in 2006. As a result of a large clinical study on EVAR, EVAR

had significantly low morbidity and mortality before and after the procedure compared

with surgical treatment, but the excellent survival rate was offset after two years that

the long-term survival rate was not different from that of the surgical treatment. More-

over, the long-term survival rate of performing a procedure again after EVAR was high-

er than that of the surgical treatment.

To improve the long-term result of EVAR, the equipment diameter has been reduced,

and devices with various sizes that can be applied to the neck diameter of a large or

small aortic aneurysm have been introduced. Moreover, the devices have been im-

proved to do implantation on the accurate location to enable insertion even if the neck

is short, and the flexibility of devices has been improved for insertion to crooked blood

vessels. Furthermore, materials have been developed to improve long-term durability;

new-generation EVAR devices have been introduced rapidly, so treatment result im-

provement is expected in the future.

2) Excellent procedure result

Korea’s current nationwide TAVI procedure results are summarized in K-TAVI Fact Sheet 2017,

and it states that the occurrence rate of cardiac death was 3.3% one year after the procedure,

and the occurrence rate of disabling stroke was 2.5% one year after the procedure; these are

world-class results.

1) Active procedure activities leading Asia

In Korea, TAVI (Transcatheter Aortic Valve Implantation) procedures are actively performed in

about 20 institutions, and the number of institutions is rapidly increasing. In Korea, the first TAVI

procedure was performed in 2011, which was during the initial phase of the TAVI procedure, and

the number of procedures is rapidly increasing, leading TAVI in Asia. Based on accumulated expe-

riences and knowledge, stable procedures are being performed.

3 Structural Heart Disease Intervention

300

250

150

200

50

100

08 10 10 17

117

279

2011 2012 2013 2014 2015 2016

Patie

nt N

umbe

r (n)

Jun 2017

187

TAVI experiences in KoreaFigure 22

28 29


(%)

15

5

10

0

2.3

In-hospital outcomes

1.21.1

2.6

1-month outcomes

1.21.4

8.9

1-month outcomes

3.3

5.6

Non-disabling stroke

Cardiac death

Source: K-TAVI Fact Sheet 2017

All causes of death: cardiac + non-cardiacFigure 23

(%)

5

1

4

3

2

0

1.2

In-hospital

0.9

0.3

1.6

1-month

1.2

0.4

3.2

1-year

2.5

0.7

Non-disabling stroke

Disabling stroke

Source: K-TAVI Fact Sheet 2017

TAVI experiences in KoreaFigure 24

A. Transcatheter aortic valve implantation (TAVI)

1 What is aortic stenosis?

Aortic stenosis (AS) is a disease in which the aortic valve does not open well because

of its narrowness, and because of the abnormality of blood flow between the heart

and the aorta, such symptoms as breathing difficulty while doing exercises, chest pain,

fainting, etc., are induced. Aortic stenosis is the most common natural valve disease,

which affects more than 300,000 people worldwide. Moreover, morbidity increases as

one ages. If a patient who has symptoms does not receive appropriate treatment, the

two-year mortality rate is up to 50%–60%, making it a very serious disease.

2 Diagnosis

(1) Electrocardiogram: It shows left ventricle hypertrophy as well as ST-segment and

T wave changes in advanced cases.

(2) Echocardiogram: Echocardiogram is the most basic and important test to diag-

nose AS. A thickened aortic valve with calcification is observed in echocardiogram.

(3) Cardiac catheterization/angiography: To evaluate the pressure load responsible

for AS, a catheter is advanced percutaneously, and the pressure difference between

the left ventricle and the aorta is determined to evaluate the severity.

Figure 25 Progression of aortic stenosis (AS) as one ages

30 31


3 Transcatheter aortic valve implantation procedure for aortic stenosis

For patients who need open-heart surgeries for aortic stenosis treatment yet cannot

receive them, the aortic valve balloon dilation was tried in the 1980s, but there was

no survival rate improvement, and the recurrence rate was 80%, so it was not widely

used. Since the early 1990s, TAVI, in which a valve stent is located in the stenosed

valve using a catheter, has been studied.

In the TAVI procedure, without opening the heart, a thick catheter is usually inserted

into the femoral artery and approached to the aortic valve. After that, a guidewire is

advanced into the left ventricle, and, if necessary, by considering the status of the

patient, anatomical aspect of the lesion, etc., balloon dilation can be performed before

artificial valve implantation. The TAVI device is now placed in the aortic valve by follow-

ing the guidewire. Based on the type of the TAVI device, the TAVI valve is implanted

through balloon expansion or self-expansion.

B. Adult congenital heart disease intervention

Interventions for adult congenital heart disease include the closure surgeries of

ASD, patent foramen ovale (PFO), PDA, etc.

1 Atrial septal defect intervention (ASD)

Atrial septal defect is a congenital heart disease that is most commonly diagnosed

for the first time in adults. Percutaneous closure surgery using devices has a similar

efficacy compared with the surgical treatment, but the number of complications of

percutaneous closure surgery using devices was less than 10%, which was lower

than the number of complications of closure surgery (20%). Compared with surgery,

the pain is less, and no scars are left in patients. There are more advantages such as

less psychological burden of patients and family, etc.

Figure 26 Transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve

Severe aortic stenosis After transcatheter aortic valve implantation

A. Before procedure B. After procedure

Figure 27 Balloon-expandable TAVI procedure

A. Aortography before the procedure. B. Location of the balloon-expandable TAVI valve in the aortic annulus. C. Implanting the valve by expanding the balloon.

Figure 28 Self-expandable TAVI procedure in the bicuspid valve

A. Aortography before the procedure. B. Locating the self-expandable TAVI valve in the aortic annulus to start the insertion. C. After the valve insertion.

32 33


C. Left atrial appendage closure by surgery (LAACS)

It is known that 90% of thrombi is in the left atrial appendage of the heart of pa-

tients with atrial fibrillation. As such, a technology has been developed to exclude the

left atrial appendage from the blood flow. It is a percutaneous intervention without a

surgical incision in the heart and can reduce the risk of stroke in patients with atrial

fibrillation. In Korea, such devices as WatchmanTM (Boston Scientific, MN, USA), Am-

platzerTM, and AmuletTM (St. Jude Medical, MN, USA) are mostly used. In particular,

if stroke occurs in a patient who may not take or does not take oral anticoagulants

properly, such a procedure can be considered.2 Patent foramen ovale intervention (PFO)

For patients who have suffered from a cryptogenic stroke, to prevent the recurrence

of stroke, PFO intervention can be done to close it. For patients with migraine accom-

panied by PFO, the closure can improve the symptoms. Although the closure effect

of PFO is not firmly established in theory, in recent studies, in particular, with regard

to patients with a large PFO, it has been reported that closure has a better long-term

prognosis than pharmacotherapy alone. Moreover, it has the advantage that a percuta-

neous intervention can be used to close it without a surgical incision.

3 Patent ductus arteriosus intervention (PDA)

In some patients, ductus arteriosus persists without being closed naturally that the

connection between the aorta and the pulmonary artery is maintained, and in this

case, the left ventricle is burdened, and pulmonary hypertension is induced. Even if

a small patent ductus arteriosus does not produce a symptom, it increases the risk

of endarteritis so that, for most cases except for a very small lesion, the closure of

patent ductus arteriosus is recommended. Patent ductus arteriosus can also be closed

through percutaneous intervention that it is acknowledged as the primary treatment.

Figure 29 Atrial septal defect closure device

Figure 30 Closure device implanted in the atrial septal defect area

Figure 31 Left atrial appendage closure by surgery

A. Before implanting the AmuletTM device in the left atrial appendage of a patient with atrial fibrillation. B. After implantation.

35

Smartcare-HEART

34


Korea’s Excellent Cardiovascular Intervention Cases3

1 Case of left Main Coronary Artery Percutaneous Coronary Intervention Via the Radial Artery in a Patient with Angina

A 63-year-old British professor who was working in Korea visited Hospital A and received as-

sessment on a chest pain that had occurred during exercises for two months. The patient visited

Hospital B for these symptoms and had a positive result in the exercise stress electrocardiog-

raphy that he was then referred to Hospital A. In echocardiogram, akinesia was observed in the

myocardial wall to which LCX usually supplies blood, so cardiovascular angiography via the right

radial artery was performed.

In the area in which the left main coronary artery is divided into three branches (LAD, LCX, and

ramus intermedius), a severe stenosis was found. Therefore, after discussing with the patient

about the treatment plan, stenting was planned to be performed on the test day, and it was

confirmed that the previously observed stenosis before the procedure disappeared in the angio-

graphic images after the procedure.

Left main coronary artery intervention via the radial artery. In coronary angiography, the stenosis between the distal part of the left main coronary artery and the origin of the left anterior descending artery (LAD) (arrow-head), stenosis of the origin of the left circumflex artery (LCX) (arrow), and proximal part of the LAD (empty arrow) were observed.

Figure 32

T procedure was successfully completed without complications, and as it was a procedure via

the radial artery, the patient could do simple movements right after being stabilized for about 3

hr. The patient was discharged the next day and returned to his daily life. After that, in the outpa-

tient clinic, the patient did not report chest pain during exercises. Two years after the procedure,

the local akinesia of the myocardial wall was not observed anymore in the echocardiogram. In

the cardiovascular angiography, it was confirmed that the lumen of the inserted stent was well

maintained, and no new stenosis was observed. Until now, for four years after the procedure, the

patient has been stably followed up without having a symptom in the outpatient clinic.

After stenting, the stenosis observed in Figure 32 was resolved.Figure 33

36 37

Smartcare-HEARTKorea’s Excellent Cardiovascular Intervention Cases

In echocardiogram, there was a scar of an old myocardial infarction, and the left ventricle ejec-

tion fraction was 42%, so it was judged that revascularization would be helpful. The heart treat-

ment team that was composed of cardiologists and cardiothoracic surgeons evaluated the patient

status, and decided to open the chronic complete blockage lesion with coronary intervention

rather than a surgery. With world-class high-tech medical devices—such as a guidewire special-

ized for chronic complete blockage lesion, microcatheter, balloon catheter, coronary artery stent,

etc.—the experienced medical staff performed the right coronary artery procedure successfully

to regain normal blood flow. The symptom of respiratory difficulty of the patient greatly improved

after receiving the procedure, and the patient received good treatment for his accompanying dis-

eases while being hospitalized and was discharged.

A 54-year-old man was hospitalized to receive a comprehensive heart exam because of res-

piratory difficulty. The patient had a medical history of diabetes and interstitial pneumonia, and

received interventions of the coronary artery and the lower limb artery at another hospital. More-

over, the patient received coronary angiography a year ago. Chronic complete blockage lesions

in the right coronary artery and LCX were observed, and the patient could barely do any activity

because of respiratory difficulty at that time.

Angiographic images that show the chronic complete blockage lesions of the right coronary artery and the left circumflex artery (LCX). The arrow indicates the beginning point of complete blockage, and the dotted line indicates the blood vessels that were supposed to be seen there.

Figure 34

2 Case of Intervention for the Chronic Complete Blockage of the right Coronary Artery in a Patient with Respiratory Difficulty

3 Case of Hybrid Peripheral Artery Intervention in a Patient with Lower Limb Ischemia

A. A procedure for a chronic complete blockage lesion was performed by inserting multiple guidewires and microcatheters together. B. After a successful procedure, the right coronary artery was revascularized.

A. B.

An 80-year-old man came to the hospital because of left leg pain and ischemic necrosis of the

third and fourth toes of his left foot. The patient had left hemiplegia because of stroke about 20

years ago and had ischemic pain in the left leg for eight years. Moreover, the patient received

orthopedic treatment about 10 days before coming to the hospital because of pain deterioration.

The corresponding medical staff recommended lower limb amputation, but the patient and his

family did not want amputation and looked for another treatment method; the patient came to

this hospital after hearing about the peripheral artery intervention of the cardiology department.

In the lower extremity CT angiography performed after hospitalization, arteriosclerotic vascular

occlusion was observed from the left common iliac artery to the left superficial femoral artery

and blood vessels below the left knee. As the left blood vessel was long and the stenotic degree

was severe, the hybrid procedure was decided after discussing with the cardiothoracic surgery

department. Therefore, the cardiothoracic surgery department performed endarterectomy on the

left common femoral artery and conducted percutaneous transluminal angioplasty (PTA) between

the common iliac artery and below-the-knee artery.

Figure 35

38 39

Smartcare-HEARTKorea’s Excellent Cardiovascular Intervention Cases

An 80-year-old man, Mr. Lee, came to Hospital A because of respiratory difficulty and chest dis-

comfort that occurred during exercises for two months. These symptoms made the patient visit

Hospital B first, and in echocardiogram, he was diagnosed with severe AS. While receiving tests

in the hospital, the patient complained right upper abdominal pain, and reported general weak-

ness and respiratory difficulty. His general status deteriorated rapidly, and multiple organ dysfunc-

tion was shown because of ischemic damages caused by reduced tissue perfusion pressure.

Thus, it was judged that the severe AS had to be resolved as soon as possible, so an emergen-

cy aortic replacement through open-heart surgery was requested to the cardiothoracic surgery

department. However, the cardiothoracic surgery department responded that the surgery risk

was too high at that time that the surgery could be performed only after providing the patient

with medical treatment for improvement. However, there was no way that the general status of

the patient could be improved without resolving the severe AS, so the emergency TAVI procedure

was decided. After the TAVI procedure, in the transesophageal ultrasound, it was confirmed that

the valve was operating properly.

Endarterectomy was performed by the cardiothoracic surgery department, and atheroma was removed

Figure 36

A. Left: Thrombotic occlusion of the origin of the left common iliac artery before procedure (arrow). B. Right: Successful revascularization after performing percutaneous transluminal angioplasty (PTA) by the cardiology department after surgery by the cardiothoracic surgery department (arrow)

A. B.

Figure 37

A. Severe calcification (left) was observed in angiography before the procedure B. Right before inserting CoreValve® (26 mm) C. Confirming the valvular function after inserting CoreValve®

Case of emergency transcatheter aortic valve implantation in a patient with severe aortic stenosis

Figure 38

4 Case of Emergency Transcatheter Aortic Valve Implantation in a Patient with Severe Aortic Stenosis

40 41

Korea’s Excellent Cardiovascular Intervention Cases

4

Post- departure

3

During stay

2

On arrival

1

Pre- arrival

Real-time Online System

•�one-click Medical information, consultation•�medicalpackage.visitmedicalkorea.com•�After treatment reservation is confirmed, Korean hospital

will send a concierge service request.

Fast Track Immigration & Airport Pick-up

•�Fast Track Immigration service is available at Incheon airport •�Ambulance accompanied

by medical staff and accommodation transfer is provided with request

Post-care Services

•�U-Healthcare System allows medical care staying cooperated with patients’ doctor in their home countries•�Telemedicine centers to

strengthen post-care services

Customized Services for patients and Families

•�Medical ServicesMedical related services are provided by each designated hospitals such as escort to medical appointments and examinations, interpretation (Arabic, English, Korean, ect.) •�Non-Medical Services�Center for Middle East provides Non- medical Services such as visa extension, 24/7 medical call, help desk, monitoring and reporting for patients and family.

The patient produced urine right after the procedure, and the blood test result stabilized rapidly

that the patient was discharged 16 days after the procedure without complications. After that, in

the outpatient clinic, the patient has been stably followed up for three years without showing a

particular symptom or an abnormal finding.

Confirming the TAVI valve function after the procedure through transesophageal ultrasound

Figure 39

One-stop Medical Service for International Patients4Cardiovascular

Intervention

1 One-stop Medical Services for Foreign Patients

43

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42


Korea’s Cardiovascular Intervention–Certified Medical Institutions

No. Name of Institution Region

1 Asan Medical Center Seoul

2 Chung-Ang University Hospital Seoul

3 Gangnam Severance Hospital Seoul

4 Hanyang University Seoul Hospital Seoul

5 Konkuk University Medical Center Seoul

6 Korea University Anam Hospital Seoul

7 Kyung Hee University Hospital at Gangdong Seoul

8 Samsung Medical Center Seoul

9 Seoul National University Hospital Seoul

10Seoul St. Mary's Hospital of the Catholic

University of KoreaSeoul

11 SoonChunHyang University Hospital, Seoul Seoul

12 Severance Hospital Seoul

13 Gachon University Gil Medical Center Incheon

14 Inha University Hospital Incheon

15 Mediplex Sejiong Hospital Incheon

* Top 30 medical institutions having the medical department (cardiology) that attracts international patients

No. Name of Institution Region

16 Ajou University Hospital Gyeonggi-do

17 Good Morning Hospital Gyeonggi-do

18 Myongji Hospital Gyeonggi-do

19 Sejong General Hospital Gyeonggi-do

20 Seoul National University Bundang Hospital Gyeonggi-do

21 SoonChunHyang University Hospital, Bucheon Gyeonggi-do

22The Catholic University of Korea Uijeongbu

St. Mary’s Hospital Gyeonggi-do

23 Daejeon Sun Hospital Daejeon

24 Eulji University Hospital Daejeon

25 Daegu Catholic University Medical Center Daegu

26 Keimyung University Dongsan Medical Center Daegu

27 Yeungnam University Medical Center Daegu

28 Dong-a University Hospital Busan

29 Inje University Haeundae Paik Hospital Busan

30 Kosin University Gospel Hospital Busan

It is a policy that if the medical institution satisfies the guideline established and

presented as the interventional medical service standard based on specialized medical

information, the medical institution will receive an intervention certification and will be

acknowledged as certified.

What is an intervention certification system?

52 Top 30 Medical Institutions Among Cardiovascular Intervention–

Certified Institutions that Attract International Patients

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